Merced County Department of Mental Health P.O. Box 2087 Merced, CA MEDI-CAL NETWORK PROVIDER APPLICATION

Transcription

1 Merced County Department of Mental Health P.O. Box 2087 Merced, CA MEDI-CAL NETWORK PROVIDER APPLICATION

2 Merced County Department of Mental Health P.O. Box 2087 Merced, CA Phone: (209) Fax: (209) Dear Applicant, Thank you for your interest in participating as a Medi-Cal Network Provider in the Mental Health Plan of Merced County Department of Mental Health. Please read the enclosed General Instructions prior to completing the application. Upon receiving your completed application, you will be notified by mail in regards to your status as a Medi-Cal Provider in the Mental Health Plan of Merced County Department of Mental Health. Please note that you must be an approved provider before the MHP is able to render payment for services. Should you have any questions regarding this application, please feel free to contact me at (209) Thank you. Sincerely, Evelyn Egger, RN, Quality Improvement Program Manager EEgger@co.merced.ca.us

3 GENERAL INSTRUCTIONS: Application must be typed or printed legibly; curriculum vitae will not be accepted in lieu of a completed application. If there is insufficient room for any question, additional sheets will be accepted. Please make reference to the question number if an additional sheet is used. Please include: Copy of current DEA Certification, if applicable Copy of current Professional License Copy of Professional Board Certification, if applicable Copy of current Professional Liability Insurance Certificate Copy of current W-9

4 PROVIDER INFORMATION: Last Name: First Name: MI: SSN/Tax ID: Gender: DOB: License Type: Specialty: NPI: PRIMARY OFFICE(S): If more than one, please use separate sheet. Office Address: Billing Address: Same as office address Phone Number: Fax Number: 1. Is your office wheelchair accessible? Yes No 2. Does your office have parking on site? Yes No 3. Is your office located near public transportation? Yes No 4. Do you dispense and maintain medications? Yes No 5. Do you have a Fire Clearance? Yes No 6. Are you available 24/7 with a back-up provider? Yes No If yes, who is the provider? PRACTICE INFORMATION: Make checks payable to: If practicing as a corporation, identify name: If you are part of a group, list names of other providers in group who will also participate:

5 Are you currently employed elsewhere in addition to private practice? Yes No If yes, please provide employer information: Employer Name: Address: Phone: Contact: LICENSE INFORMATION: TYPE OF LICENSE LICENSE # STATE ISSUED DATE ISSUED Medi-Cal Provider # DEA #: Medicare UPIN: DEA Expiration Date: BOARD CERTIFICATION: Have you applied for board certification? Yes No NAME OF BOARD CERT. NUMBER CERT. DATE EXPIRATION DATE Are you currently credentialed with any other Mental Health Plan? Yes No If yes, please list name of county/counties: CURRENT HOSPITAL AFFILIATION(S), if applicable: NAME TEAM/DEPT APPT DATE STATUS

6 RESIDENCIES, FELLOWSHIPS, TRAINING, INTERNSHIPS: Include preceptor ships, teaching appointments, and postgraduate education starting with the most recent. FACILITY NAME/ADDRESS PROGRAM DIRECTOR TYPE OF TRAINING/SPECIALTY FROM: TO: MEMBERSHIP IN PROFESSIONAL SOCITIES/ORGANIZATIONS: NAME OF ORGANIZATION MEMBERSHIP STATUS FROM: TO: MEDICAL/PROFESSIONAL EDUCATION PROFILE: MEDICAL/PROFESSIONAL SCHOOL MAILING ADDRESS DEGREE RECEIVED DATE GRADUATED

7 CONTINUING EDUCATION: List all postgraduate activities in which you have attended or for which you have received credit within the past two years. ACTIVITY AGENCY HOURS DATE COMPLETED PROFESSIONAL LIABILITY: INSURANCE CARRIER POLICY HOLDER LIMITS OF LIABILITY EFFECTIVE DATE: EXPIRATION DATE: LANGUAGES: Please identify languages, other than English, including American Sign Language, in which you are proficient:

8 WORK HISTORY: List work history since completion of postgraduate training, explain any gaps in employment. Name of Practice/Agency: Mailing Address Contact From: To: CLINICAL SPECIALTY: Please complete the following so that we may best match beneficiary clinical needs with characteristics of your practice. Populations Yes No Problems Yes No Tx Modality Yes No Adolescents (12-17) ACA/Co-Dependence Couples Therapy Adult (18-65) Critical Incident Debriefing Crisis Intervention Blind Disability Evaluation ECT Children (1-4) Domestic Violence Family Therapy Children (5-11) Forensics Group Therapy Deaf HIV/AIDS Individual Therapy Gay/Lesbian Job Stress Medication Monitoring Geriatric Other: Other: Older Adult (65+) Pain management Psychological Testing Other: Sexual Abuse Physical Disability Trauma Women

9 Disorder Yes No Disorder Yes No Adjustment Disorders Feeding and Eating Disorders Anxiety Disorders Gender Identity Disorders Attention Deficit/Disruptive Impulse Control Disorders Disorders Bipolar Disorders (Moderate) Medication Induced Movement Disorders Bipolar Disorders (Severe) Mood Disorders (Moderate) Dissociative Disorders Mood Disorders (Severe with Psychosis) Eating Disorders Disorders of Infancy Elimination Disorders Paraphilias Factitious Disorders Pervasive Developmental Disorders Personality Disorders Schizophrenia CULTURAL COMPETENCE: Please identify: ATTESTATION: Question Yes No Has your clinical license or DEA registration ever been revoked, suspended, or limited? Have you been the recipient of adverse actions, or surrendered clinical privileges while under investigation for possible actions such as: revocation, suspension, limitation, disciplinary review, denial, or cancellation of license? Is any action pending by: Medicare, Medicaid, any public program, hospital medical staff, clinical group, independent practice association, professional school faculty or other health delivery entity or system? Have you ever been convicted of a felony? Have you ever had any professional liability claims? If yes, please provide details on the back of this page. I certify that the information provided on this application is accurate and complete. I authorize the Mental Health Plan to verify all of the information provided in this application. Signature/Title/Date

10 STATEMENT OF UNDERSTANDING I hereby certify that the information provided in this is true and accurate and reflects my current level of training, experience, and demonstrates competence to practice within my clinical expertise. I understand that I have the burden and legal responsibility to provide true and adequate information to demonstrate my professional competence, character, moral ethics, and other qualifications. I hereby consent to the disclosure and inspection of information and documents relating to my credentials and qualifications by and between Merced County Department of Mental Health and other health care organizations, licensing authorities, businesses and individuals acting as their agents for the purpose for the evaluation of this credentialing or re-credentialing application regarding my professional training, experience, character, conduct, judgment, ethics, and ability to work with others. In this regard, the utmost care shall be taken in safeguarding the privacy of patients and the confidentiality of patient records, and to protect peer review information from being further disclosed. I hereby affirm that the information submitted and any addenda thereto are true to the best of my knowledge and belie and are furnished in good faith. I understand that significant omissions or misrepresentation may result in denial or termination of my privileges. Signature/Title/Date